Basic Information
| Provider Information | |||||||||
| NPI: | 1285062877 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEINACKER | ||||||||
| FirstName: | WILLIAM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 251 N BAYOU ST | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366035827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516908158 | ||||||||
| FaxNumber: | 2515442188 | ||||||||
| Practice Location | |||||||||
| Address1: | 4547 SAINT STEPHENS RD | ||||||||
| Address2: | |||||||||
| City: | PRICHARD | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366133563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514561399 | ||||||||
| FaxNumber: | 2514560079 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2013 | ||||||||
| LastUpdateDate: | 10/17/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | LNO 6048 | AL | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 011846 | 01 | AL | MEDICARE GROUP PAYEE NUMBER | OTHER | 1063439065 | 01 | AL | NPI GROUP PAYEE NUMBER | OTHER | 630000013 | 05 | AL | MEDICAID |